Psychoanalysis
Psychoanalysis is an effective treatment in patients with histrionic personality disorder who are motivated to obtain the maximum possible degree of personal understanding and self-development. To be most effective, this form of treatment should be used for patients in whom the narcissistic vulnerability and absence of supraordinate self-conceptualizations are not too severe to tolerate the ambiguities of role and reduction in supportive contexts that can occur in such treatments. Such approaches in well-selected patients who meet the criteria of analyzability will require 400 to 1,000 hours of treatment in order to fully explore the childhood antecedents of current irrational beliefs and motivational scenarios, to allow transference regressions to fully evolve and undergo resolution, and to learn and evolve new ways of using the mind as a tool for reflection, planning, and understanding new opportunities.

Marital Therapy
Marital therapy may be a useful addition to an individual treatment program when formulations identify neurotic cogwheeling with the partner. The partner may be reinforcing maladaptive patterns and preventing the patient from learning new and more adaptive patterns. For example, the patient may improve in individual psychotherapy and begin to practice a self-enhancing assertiveness with less masochistic submission in the hope of gaining love and attention. More assertiveness and less passivity may challenge the self-esteem of a narcissistic partner or may threaten a compulsive partner who wants to be in control of the marriage. The uncertainty of new behaviors and new relationship patterns will cause anxiety about the endurance of the attachment. Identification of such concerns can help both partners and the “we” of the marriage advance to greater satisfaction, which will reduce the overall levels of anxiety and depression in both partners.

Group Therapy
Group therapy may also be a useful addition to individual case formulation and treatment sessions. The group begins to help the patient by providing attention and emotional support. Once a sense of safety and commitment to mutual advancement are developed, group members can also help the patient by giving feedback on their reactions to the patient’s habitual behaviors. By mass effect, the group can also counteract disavowals that the patient may generate in response to interpretations by the therapist, saying in effect “Well, that’s just what you think” to any individual. Of even more utility, the group may help model alternative behavioral styles and engage in role-playing of how to handle prototypically difficult situations for the patient (and also how not to handle them, by role-playing bad outcomes of gambits that may initially relieve tensions).

Time-Limited, Brief Therapy
Time-limited, brief therapy can be helpful when intensive psychotherapy, with its longer duration, is not practicable. Unfortunately, however, there seems to exist a principle that “the rich get richer.” Patients who are relatively mature, in terms of organizational level of schematization of self and others, usually benefit more than those who have more narcissistic vulnerability and more dissociation between role-relationship models.

A focus is desirable but sometimes difficult to achieve in initial sessions due to the diffuse, wandering discourse of some patients. One can strive to define an initial focus and then modify it as more inferences occur. Recent stressor life events and what they mean to the patient can serve as such an initial focus, linking the memory of the stressor event to reactive ideas and emotions and making good plans for how to cope.

Such brief therapy approaches may help patients get through a crisis and gain some reduction in the psychiatric symptoms exacerbated by it. Further change may be possible and seems to take place in the months after termination of the brief treatment. The process of change seems to take place by the patient recognizing aspects of a maladaptive pattern and in real life attempting a series of new alternative behaviors, which leads to more recognition and more repetitions of initiatives that help him or her to live well.

In some situations, brief therapy is forced on the patient and therapist as the only vehicle permitted by an institution. In such instances, brief therapies may be usefully linked across time periods. In other words, the patient may receive a brief therapy now and be expected to return when another allotment is permitted, perhaps in the next year. Here is when case formulation is essential. What is learned in the first treatment should be carried over as organized inferences about the patient into the next treatment. The more that formulations can be in common language and understood by the patient, the more the patient can carry and revise what has been gained. Systematic efforts at case formulation will also help form useful professional records, which can then become useful in such linkages between episodes of time-limited treatments. A change process can usefully extend over years, with periods of psychotherapy as facilitations to self-developmental efforts.

Conclusions

Four phases of formulation and treatment are described in this chapter. Although these four phases have been discussed as though they occur in a sequence, in actual treatment the phases overlap. As therapy proceeds, the list of problems expands, and some items are dropped off as improvement occurs. The attention to undermodulated states of mind is less necessary. Individualized state descriptions become more important and are related to specified beliefs about self and others. Motives are considered in terms of what states and role-relationship models the individual desires and what states and role-relationship models threaten them. Defenses continue to be identified and modified as layers of identity, values, wishes, and fears are examined in configurations of conflict. Reductions in conflict make defenses less necessary, and emotions both become more authentic in expression and are seldom felt as out of control. Interpersonal activities show marked improvement as such change processes occur.